Nokea
The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?
- A. Discontinue the exchange and collect a peritoneal fluid specimen for culture and sensitivity.
- B. Warm the remaining dialysate fluid and increase the dwell time of the exchange.
- C. Administer a dose of oxycodone prescribed PRN for the client.
- D. Place the client in the high-Fowler position in bed.
Correct Answer: A
Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (A). Warming dialysate (B), pain medication (C), and positioning (D) do not address the infection.
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The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.
The nurse is talking with the parents of a 4-year-old client. The parents are concerned because the client was previously toilet trained but has started wetting the bed again while hospitalized. Which of the following responses would be most appropriate for the nurse to make?
- A. Reinforcing any forgotten toileting behaviors during the hospital stay is beneficial.
- B. Restricting your child's fluid intake at night will resolve this issue.
- C. Your child may be purposefully misbehaving to gain your attention during the hospital stay.
- D. Your child may be reverting to behaviors from an earlier stage of development to cope with stress.
Correct Answer: D
Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress (D). Reinforcing toileting behaviors (A) may help but doesn't address the underlying cause. Fluid restriction (B) is not appropriate without medical indication. Assuming misbehavior (C) dismisses the emotional impact of hospitalization.
The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?
- A. Tell the family they can bring in a pizza if the patient would prefer that.
- B. Make sure the patient gets at least 2 cartons of milk
- C. Stop the IV if the patient is able to eat solid food.
- D. Encourage the patient to eat slowly to prevent gas.
Correct Answer: D
Rationale: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.
The nurse is caring for a man who has recently been diagnosed with angina. Which statement he makes indicates understanding of his condition?
- A. I should not exercise now that I have angina.'
- B. If I have chest pain, I will take nitroglycerin.'
- C. Sexual activity is likely to cause a heart attack.'
- D. If I have any chest pain, I should immediately call my doctor.'
Correct Answer: B
Rationale: Taking nitroglycerin for chest pain reflects proper angina management. Avoiding exercise, fearing heart attacks, or calling for all pain are misconceptions.
A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?
- A. Crackers and cheddar cheese
- B. Hard-boiled egg with tomatoes
- C. Steamed fish and potatoes
- D. Tortilla chips with avocado dip
Correct Answer: C
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (A) to prevent hypertensive crisis. Fish and potatoes (C) are safe and nutritious. Eggs (B) and avocado (D) are safe but less balanced.